Monday, June 06, 2011

The Rise of Specialty Hospitalists

It started as just a figment of the hospitalist movement years ago when I saw an ad in Florida advertising for a cardiology hospitalist. Now it seems the trend is continuing to other specialties like neurosurgical, orthopedic, OB-GYN, and ENT hospitalists.

In the new construct of health care reform ahead, will specialists evolve to mere proceduralists?

If so, should we insist our hospitalist colleagues obtain additional specialty training and board certification in their chosen "specialty" fields? Or is a mere "label change" of the hospitalist title enough to assure quality care for our patients?

This trend toward lower-cost, less-trained individuals subsuming titles of "specialists" so hospitals can meet their bottom lines leaves me lukewarm regarding patient care quality. Yet ironically, I suspect that 90% of things we do day to day in my field will be managed fine by this construct.

It's just the other 10% of cases that aren't routine that I remain concerned about. It's like that old Harry Callahan line spoken by Clint Eastwood in the movie Dirty Harry:

I know what you're thinking. "Did he fire six shots or only five?" Well, to tell you the truth, in all this excitement I kind of lost track myself. But being as this is a .44 Magnum, the most powerful handgun in the world, and would blow your head clean off, you've got to ask yourself one question: Do I feel lucky? ... Well, do ya, punk?

6 comments:

Josh,Physicians don't do "public health." We do personal health. The addition of public health policies and political science to health care are like asking an accountant how to fix the Hubble Spacecraft. He could come up with all kinds of numbers related to the project which not would help the astronauts in space. He could also come up with less and more expensive ways to get the job done. To the astronauts, he's not even in the same universe they are. The "Let's try something even if it proves to be wrong" approach does not help the patient. If, after a few years, everyone decides that specialty hospitalists was a bad idea, how many patients, doctors and hospitals have had to suufer through the "experiment?" Public health and poly sci look at the country as a laboratory. Doctors see patients one at a time, as a person with a life altering situation, and try to get them back to a normal life. The last thing we need are "population" experts looking over our shoulders, saying, "Why don't you try a little of this."The trend toward less well-trained purveyors of health care has been going on for a while. Each new echelon is supposed to be a physician extender, whether they be nurse practitioners or physician's assistants, supervised by a physician. What they become is substitutes with little or no supervision until someone says, "See! I told you it could be done with less training!" Before you know it, there will be a course, 12 Month Crash Course in Medical Care! 2 Months Extra for Specialization! The only crash will be patients dying! Of course, when you're dead, the accountants will note that you won't require the expenditure of any more health care dollars!

I had the great misfortune of having an extended hospital stay over a holiday weekend. I was being trated by both a specialist and my PCP. However, due to the holiday, I was 'turned over' to the hospitalist(s). Never again. For an upcoming surgery I have requested that only my PCP, the surgeon and my specialist be involved. And they have agreed.The implementation of the 'hospitalist' system might be a cost cutting measure, perhaps a time saving measure, probably a political matter between hospital staff and independent practitioners. I don't know the reasons behind the system. Whatever the reason, my experience is that the patient suffers. And isn't that the imporant issue in the entire discussion? And the thought of 'specialty' hospitalists is terrifying.

I suspect your doctors will plan to take at least some of their weekends (especially holidays) off so they can decompress and spend time with their families. If future admissions span holiday weekends, it is likely that you'll run into the same problem.

When your doctors are not available to see you, some type of backup system will need to be in place. It is incumbent on the primary physicians to communicate well with those covering. It is also the hospital's responsibility to hire capable hospitalists.

You may not have as much luck having consistent access to your personal MDs as you'd like. When they are not seeing you, it's probably because they are seeing other patients or taking deserved time off.

One approach would be to see a "concierge" MD. Generally these doctors will provide enhanced access and communication for an additional fee that you pay.

Isn't it true that many of these specialists are already behaving like proceduralists? Performing the procedure and then dumping on the hospitalist? Would this "problem" exist if specialists followed up on their patients appropriately? Sounds sort of like "we don't want to do it but we don't want you to do it either."

Jay - no doubt you are right. I never thought I would want to live in a "Marcus Welby, MD" era...I have a concierge MD and pay dearly for it. I understand the need for MDs to decompress, recharge and step away for some personal time. My expectation is that the hospitalists actually read my file, understand the issue(s) and communicate with my physicians even if this means something in addition to a notation on an EMR. I'm naive enought to want top notch medical care all the time, not just part of the time. And my experience is that that is NOT the case when a variety of hospitalists get involved and do no more than monitor blood work.

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.